Updated AS and NrxSpA Treatment Recommendations Identify Common Diagnosis Issues, Solutions

The American College of Rheumatology (ACR) released updated recommendations for the treatment of Ankylosing Spondylitis (AS) and Nonradiographic Axial Spondyloarthritis (NrxSpA). 

Researchers took clinical questions on pharmacological treatment addressed in the 2015 guidelines. They conducted systematic literature reviews with 26 new questions on pharmacological treatment, treat-to-target strategy, and the use of imaging. New topics such as the use of secukinumab, ixekizumab, biologic tapering, and treatment discontinuation were also included.  

“This update was primarily motivated by the availability of new treatment options, notably secukinumab, ixekizumab, tofacitinib, and TNFi biosimilars, for patients with axSpA,” said researchers. “Providers and patients have questions on where these new medications fit in the pharmacological strategy, and how originator TNFi, sulfasalazine, and NSAIDs should be used given these new options.” 

The quality of evidence was assessed, and recommendations were formulated using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) method. A minimum of 70% agreement among the voting panel was required. 

Overall updated recommendations concluded that:   

• AS and NrxSpA had similar recommendations.  
• TNFi was suggested as a first-choice biologic treatment rather than secukinumab or ixekizumab. However, if a patient does not respond well to the first TNFi, it is recommended to try secukinumab or ixekizumab as an alternative.  
• TNFi, secukinumab, and ixekizumab are all preferred over tofacitinib.  
• Researchers do not recommended to combining low-dose methotrexate with TNFi, following a strict treat-to-target strategy, or discontinuing/tapering biologics in patients with stable disease.  
• Providers should only use sulfasalazine for persistent peripheral arthritis if TNFi is not an option. 
• Magnetic resonance imaging of the spine or pelvis may be helpful in assessing disease activity for patients with uncertain status. It is not necessary to regularly monitor radiographic changes with serial spine radiographs. 

“This update addressed only a subset of treatment questions,” said researchers.  “Application of these recommendations must be individualized, and requires careful assessment, sound clinical judgment of each patient’s circumstances, and consideration of patient’s preferences.” 

Reference  

Ward MM, Deodhar A, Gensler LS, et all. 2019 update of the american college of rheumatology/spondylitis association of america/spondyloarthritis research and treatment network recommendations for the treatment of ankylosing spondylitis and nonradiographic axial spondyloarthritis. Arthritis Care & Research. 2019;71(10):1285–1299. doi:10.1002/acr.24025